17-07-2025
These are not sleepy eyes, but a weakness of the eyelids
Cataracts are a common condition when you get older, but unbeknownst to many, there are also other eye conditions that affect the elderly.
According to The National Eye Survey III, more than 160,000 Malaysians aged 50 and above suffer from low vision, with 8% blind due to cataract, diabetic retinopathy and glaucoma.
A further 13.5% of adults – particularly those over 60 – have ptosis, while 17% of those aged 80 and above have ectropion.
However, these figures are not reflective of the actual numbers in the country, as the survey, conducted from July to October 2023, was only carried out in Kelantan, Pahang, Terengganu and Sarawak.
Upper eyelid problem
A non-surgical solution for ptosis is a 'crutch' attached to a pair of glasses, which help elevate the drooping eyelid.
Ptosis is a condition where the upper eyelid droops.
It can affect one (unilateral) or both (bilateral) eyes.
'This is often due to laxity or weakness in the muscle that elevates the upper eyelid, causing it to droop.
'It's normally due to age-related changes, but can also be caused by a stroke which has affected the third cranial nerve palsy,' says consultant ophthalmologist and oculoplastic surgeon Dr Kala Sumugam.
A palsy of the third cranial nerve can impair either eye movements or the response of pupils to light, or both.
It can occur when pressure is put on the nerve or if the nerve does not get enough blood supply.
It can also result from direct trauma to the muscle, such as a fall or eye injury that leads to eye swelling.
Once the swelling settles, the droopiness of the upper eyelid becomes obvious as the eye looks smaller or partially closed.
Before diagnosing ptosis, doctors also need to rule out myasthenia gravis, a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscles, resulting in muscle weakness.
Myasthenia gravis affects the voluntary muscles of the body, especially those that control the eyes, mouth, throat and limbs.
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Dr Kala says: 'It's also important to differentiate ptosis from pseudoptosis, which is caused by the weight of the eyelid skin.
'[In such a case,] the eyelid skin is too thick and pushes down to cover part of the pupil.
'With ptosis, patients will come in complaining of compensatory postures, such as persistently having to lift their chin, which causes neck discomfort, and/or overarching or lifting their eyebrows up to see better.
'They can also get frequent headaches from doing this for long periods.
'If the ptosis is very severe, their superior visual field is obscured – they can't see the top part, so their view is restricted and they might be knocking into things.'
Unfortunately, because the condition is due to age-related changes, there are no preventative exercises or methods to keep it away.
Treatment includes surgery to tighten the weakened muscle.
'It's a daycare procedure where we make a skin incision on the affected eyelid, identify the weakened muscle and attach it back to its original position [i.e. levator advancement surgery].
'We either use their own tendon to anchor the eyelid, or silicon.
'It's not a cosmetic surgery as the patient has a functional condition where the vision is obscured or compromised,' she says.
For patients who cannot undergo surgery, there are temporary solutions.
Dr Kala says: 'We advise them to tape the eyelid upwards or use an eyelid crutch, where the de- vice is mounted on the patient's glasses to help them lift up the eyelid.
'But bear in mind that most elderly patients have a component of dry eyes, so if you tape for a long time, or use ptosis crutches, then blinking is compromised and will lead to further dry eyes.
'So the definitive approach for ptosis management is still surgery.'
However, she points out that for those with myasthenia gravis, surgical outcomes may not be as good as it is a recurrent problem, so the solution lies in getting a ptosis crutch.
The condition can also be congenital and obvious in children; however, even if the child's eye has been operated on, they can still get it again as an adult.
Lower eyelid problems
Entropion and ectropion are conditions affecting the lower eyelids. Here's a case of entropion, or the lower lid turning inwards.
Entropion is characterised by the eyelid turning inward, causing the eyelashes to rub against the eye.
Meanwhile, ectropion involves the eyelid turning outward, away from the eye.
'Patients complain of discomfort in the eye due to a foreign body sensation.
'With entropion, the lower eyelid is folded in, so the whole eyelash line perpetually rubs on the cornea and irritates the eye, making it red or teary.
'Left untreated, it can cause erosion of the cornea and blurry vision.
'In cases of ectropion, it is difficult or impossible to fully close the eyelid, and because the tear fold is unstable, there is a lot of tearing,' says Dr Kala.
Patients are required to undergo a visual field test – a method used to assess a person's peripheral vision, or how much they can see to the sides, top and bottom, while looking straight ahead.
Then, by staining the eyes, doctors will also look for any erosion or scarring of the cornea, eye dryness, and in some cases, ulcers from the constant irritation.
Depending on the severity of the condition, treatment measures include taping the eyelid for entropion patients, but for ectropion, patients are told to use lots of lubricant to prevent the cornea from being affected. With entropion cases, the temporary solution is to tape the lower eyelid to prevent the eyelash from touching the cornea.
Dr Kala says: 'Ultimately, surgery is best to tighten the muscle as the outcomes can last for 10-15 years.
'For entropion patients who cannot go through surgery, we can also put sutures to evert [turn inside out] the lower eyelid to bring relief.
'This can last anywhere from three to six months, and patients can return to do the procedure again.'
Besides the elderly, lower eyelid abnormalities can also strike those with occupations that require being under the sun, such as gardeners.
The ultraviolet (UV) light from the sun can cause the eye muscles to get lax, so it is best to wear sunglasses for protection.
Which surgery first?
Dr Kala checks a patient's eye for abnormalities. She notes that ptosis, entropion and ectropion are unfortunately unpreventable. — SAMUEL ONG/The Star
Should the patient have cataracts along with any of the eyelid conditions mentioned above, Dr Kala advises getting their cataracts removed first.
This is because during a cataract surgery, there is some manipulation of the eyelid.
'If we do a ptosis correction and that patient goes into cataract surgery later, the doctor will pry open the eye with a spectrum, so the chances of ptosis recurrence is there.
'If, at that point, the cataract is mild, but ptosis is severe, then go ahead with the ptosis correction first.
'We can't do both surgeries together as every surgery carries a risk of infection and swelling,' she says.
One out of every 10 elderly patients who walks into Dr Kala's clinic daily have either ptosis, entropion or ectropion.
All patients want to be able to see well.
'It's important to give them a good outcome and make sure their eyes are symmetrical,' she says.
'For ptosis, there will be some amount of under- or overcorrection, but we will counsel them beforehand.
'Once we fix the problem, they may temporarily have trouble closing the eyelid completely, but this should resolve in time.
'Having said that, it is an extremely safe procedure done under local anaesthesia as we want the patient to cooperate with us when we tell them to look up and down.'
Often, these conditions can lead to depression and anxiety, as the older person is self-conscious of how others perceive them.
So, Dr Kala's suggestion is to at least seek an opinion from an ophthalmologist instead of suffering silently in misery.
